Abstract: This article reports on the case of a patient who underwent a multidisciplinary treatment in smile design that entailed dental cosmetic techniques involving esthetic periodontal surgery, teeth bleaching, and re-anatomization of the upper incisors. The male patient presented with a chief complaint of an excessive gingival display while smiling, as well as small, darkened teeth with spaces between them. After diagnosis and patient consent, therapy began in the following stages: periodontal plastic surgery with probing, bleeding points delimitation, beveled incision, removal of the gingival band with periodontal curettes, and finishing with an electric scalpel. After 21 days following surgery, dental bleaching using a combined technique that included two sessions of in-office bleaching (35% hydrogen peroxide) and 2 weeks of at-home bleaching (carbamide peroxide 16% for 4 hours per day) was carried out, followed by dental re-anatomization using resin composite. Diagnostic waxing, mock-up, fabrication of a palatal silicone index, incremental sculpturing, and structuring the restoration of the palatal shell to the vestibular surfaces was then completed, followed by occlusal adjustment, finishing, and polishing. The multidisciplinary intervention was fundamental for the accomplishment of the proposed treatment that combined biological, functional, and esthetic concepts.

Facial expression is a vital element in nonverbal communication. A person's smile is significant when conveying thoughts and feelings.1 Darkened or discolored teeth with the presence of spaces between them and extreme gingival exposure can compromise the esthetics of one's smile, and this can affect interpersonal relationships.2-4 In this regard, the dentist is not only treating disproportions of the smile, but also assisting the patient in gaining, or regaining, self-esteem and self-confidence.5-7

A high smile line means there is full exposure of the clinical crowns of the teeth and an excessive gingival margin display when smiling.8,9 Gingival exposure that is more than 3 mm may compromise facial harmony and the relationship between white esthetics (teeth) and pink esthetics (gingiva).9-11 Commonly, a harmonious smile in youths shows up to 30% of gingival tissue and 70% of dental tissue12-14; when this proportion is incorporated into the shape of the lips, the right lip balance is achieved.15,16 The gingival or gummy smile may have its etiology related to a marked gingival growth, hyperactivity of the upper lip, excessive vertical maxillary bone growth, or a short upper lip.11,17,18 Knowledge of the etiology is fundamental in determining the treatment plan.17,18

Darkening of teeth could be related to several natural and physiologic factors, such as the intake of food and beverages that may cause tooth staining. Either in-office or at-home bleaching (or a combination of both) may be indicated as a treatment.19,20 Darkening is one of the first dental disharmonies perceived during a conversation; hence, tooth bleaching may be indicated, especially before the initiation of esthetic restorative treatment.21

Variations in tooth shape and size may lead to the presence of diastemas. These spaces usually are greater than 0.5 mm, may exist between any dental elements, and are most prevalent between incisors.22 In deciduous dentitions (Baume type I arches), there is no indication of esthetic correction.23,24 However, in permanent dentition, several therapeutic options have been described, ranging from complex orthodontic treatments to simple incremental additions of resin composite.24,25 The appropriate treatment will depend on the magnitude of the problem, as well as the patient's financial situation.24,25

This article reports a clinical case in which the patient presented with an excessive gingival display while smiling and darkened teeth with poor spacing. The treatment featured a multidisciplinary approach comprising gingival surgery, a combined dental bleaching technique, and dental re-anatomization with resin composite.

Case Report

A 29-year-old male patient visited the Postgraduate Dentistry Center (Universidade de Pernambuco, Camaragibe, Brazil) with a chief complaint of severe gingival exposure on smiling, and small darkened teeth with spaces between them. The clinical examination revealed a natural yellowing discoloration of the teeth, hypoplastic enamel spots, marked gingival exposure due to muscular hyperfunction and marked gingival growth, as well as an anterior open bite (Figure 1 and Figure 2). The patient was advised to undergo orthodontic therapy for anterior open-bite closure before receiving esthetic treatment. However, he was unwilling to do so because it would result in a more prolonged treatment.

A treatment plan was thus suggested in the following sequence: (1) gingivectomy associated with gingivoplasty between the upper right and left first premolars (ie, teeth Nos. 5 through 12); (2) dental bleaching of these teeth using a combined technique of in-office and at-home bleaching; (3) analysis of whether or not enamel microabrasion would be needed; and (4) closure of diastemas and increasing the size of the upper incisors with resin composite to improve dental proportions and minimize the open bite.

After patient acceptance of the proposed treatment plan, hemogram, coagulogram, and fasting blood glucose tests were performed to help identify any surgical risk factors and aid in the choice of anesthesia and postoperative medications. Also, periapical radiographs from upper canine to canine were taken. After establishing the baseline, the treatment started.

Gingivectomy/Gingivoplasty

Gingival contour remodeling was performed by removal of the delimited gingival band by marking bleeding points, making internal and external bevel incisions, performing tissue removal with periodontal curettes, and executing re-anatomization of the interdental papillae. The procedure was completed using electric scalpel finishing. This periodontal plastic surgery sequence is illustrated in Figure 3 through Figure 6.

Combined Dental Bleaching Technique

After 21 days of healing following the surgical procedure, the combined bleaching was performed. The treatment comprised two sessions of in-office bleaching with 35% hydrogen peroxide (Figure 7 and Figure 8) and 2 weeks of at-home bleaching with 16% carbamide peroxide for 4 hours per day (Figure 9).

The patient's condition after gingival plastic surgery and tooth bleaching is shown in Figure 10.

Dental Re-anatomization With Silicone Index

The gypsum model used to prepare the individualized tray for at-home bleaching was used for the diagnostic wax-up (Figure 11 and Figure 12). The mock-up was prepared, and dental proportions and occlusion were evaluated (Figure 13).

Sequentially, a palatal silicone index was made, and the direct resin composite restorations were done at the upper incisors (teeth Nos. 7 through 10). Initially, the color of the resin composite was selected under natural light. After a near-complete isolation of the operative field with rubber dam, tooth prophylaxis was performed with pumice paste and water. Bonding procedures were then executed with 37% phosphoric acid-etching for 30 seconds (Figure 14), washing with water/air spray for the same amount of time, air-jet drying, and, finally, application of two layers of a universal adhesive (Figure 15). After 20 seconds, air jets were applied to enhance solvent volatilization followed by light curing with a light-emitting diode (LED) unit (10 seconds at 1,700 mW/cm2).

Nanoparticle resin composites were used in this case. Initially, a clear/translucent resin composite was adapted to the palatal silicone guide for the reconstruction of the palatal shell. Care was taken at the tooth-restoration interface adaptation so as to avoid marginal ditches or overhangs. This ensured that the emergence profile would be maintained and quality gingival health preserved (Figure 16 and Figure 17).

A resin layer corresponding to the dentin (A1) and characterization was inserted and light-cured for 20 seconds (Figure 18). Finally, a resin composite corresponding to the enamel (A1) was applied on the buccal surfaces and to close the contact points (Figure 19).

The occlusal adjustment and initial finishing were performed using fine-cut diamond burs. Finishing strips were used at the approximal regions. The finishing was completed at the next session using flexible discs and rubber points. Polishing was completed using felt discs with polishing paste, thus concluding the clinical case.

Figure 20 and Figure 21 show the patient's smile and facial-tooth analysis at 1-year follow-up.

Discussion

Dentists face clinical practice challenges daily. Aligning functional, biological, and esthetic concepts with patient expectations and constraints often becomes complex.26,27 To accomplish this, communication with other specialists may be necessary to consolidate an efficient treatment. According to Stefani et al, a multidisciplinary approach is essential for diagnosis and to attain an adequate treatment plan to achieve satisfactory results and restore oral health pragmatically and conservatively.27

As seen in this case, significant gingival exposure while smiling and short clinical crowns may compromise the esthetics of a smile.18 Gingival plastic surgery was needed to reduce the exposure of the gingival margin and improve the proportionality between the teeth. Oliveira and Venturim described the achievement of a harmonious smile as a balance between several elements, including the color and size of the teeth, position of the upper lip, and amount of gingival exposure.28 Thus, conformation of a new dental zenith through periodontal surgery can promote a new proportional dental architecture.29

The administration of botulinum toxin type-A in association with periodontal plastic surgery could further minimize gingival exposure in a smile caused by muscle hyperfunction.18 However, in the present case the patient was not amenable to this treatment plan knowing that periodic re-applications would be necessary to maintain the toxin's effect. According to Pedron, after application of the first dose of botulinum toxin type-A for a gummy smile, the effect may last for approximately 3 to 6 months with progressive and reversible results.30

Before any restorative treatment s performed, the tooth shade must be assessed.31 In the present case, the treatment was indicated because of marked dental darkening. In younger patients, such as this 29-year-old, lighter-colored teeth can improve facial tooth harmonization if the tooth color is close to the eye sclera.32 The technique employed here combined in-office and at-home bleaching. According to Rezende et al, this combination enables the bleaching process to be accelerated, promotes stability of the effects achieved, and may help motivate the patient because of faster visual results.33

The initial clinical examination revealed the presence of hypoplastic spots on the enamel surface. For such conditions, microabrasion of the enamel would be indicated.34 However, after bleaching was completed, the visible spots were masked, which led to the clinical decision of not performing additional microabrasion. According to Haywood and Heymann, correction of the dental color pattern with a considerable degree of clinical success may be obtained in such cases through dental bleaching, but only if it is indicated and well-executed.35

After bleaching, a 15-day interval was taken before the restorative treatment was performed. Hydrogen peroxide can disseminate through dental enamel, releasing free radicals (O2) that continue to be liberated for at least 1 week after the end of the bleaching treatment20,33 and may compromise the adhesion of restorative materials to the structure.36 Sultan and Elkorashy suggested that the use of antioxidants (10% ascorbic acid or 10% hesperidin for 10 minutes, 1 hour after the bleaching procedure) might improve the bond strength between enamel and restoration and allow final restoration to be performed in the same session.37

After a relatively harmonious smile was obtained, dental re-anatomization was performed through the direct application of resin composite. This technique is considered minimally invasive, presents a low cost, reduces clinical time, and offers predictably good esthetic results.38 In this case, a silicone guide was used for conformation of the palatal shell, facilitating the sculpture of the restorations. The use of a guide has been reported to play a vital role in the predictability of the size and shape of teeth, serving as an alternative means of facilitating and accelerating the preparation of resin composite restorations in anterior teeth.39

Conclusion

A multidisciplinary approach often is necessary to achieve an esthetic harmony among the face, teeth, lips, and gums. In the present case, the interaction between periodontal and esthetic dentistry specialists was utilized to solve the complexity of the case while respecting biological, functional, and esthetic principles.